Distress tolerance and nicotine addiction

Distress tolerance and nicotine addiction

How long can you hold your breath? If you are a smoker, the results of this test would predict the likelihood of being successful at quitting those cigarettes. This is not because holding your breath is related to your lung capacity. Rather, it has something to do with distress tolerance.

We probably all know someone who has been unable to discontinue their cigarette habit, even in spite of numerous attempts to quit. As Richard Brown and colleagues elaborate in a recent article, smoking is very difficult to discontinue for three basic reasons: 1) It is a well-rehearsed habit. 2) Nicotine is physically addictive. 3) Smoking provides and maintains a sense of comfort. Although there are good treatments for smoking cessation, a sizable percentage of people attempting to quit never abstain from cigarettes for more than a few days, even with multiple cessation attempts across years or decades. Brown hypothesizes that this unfortunate population happens to be particularly intolerant of the inevitable distress of withdrawal from nicotine. Given that ACT is designed to promote acceptance and willingness to have these kinds of experiences, he developed a preliminary treatment program for smoking cessation with participants who reported being unable to abstain from cigarettes for more than three days over the past ten years of use. The results of this trial showed that, although everyone eventually relapsed by the 26-week follow up, the median number of days that participants abstained from cigarettes was 24, a whopping increase over their previous efforts and potentially a precursor to more successful attempts in the future.

Clinical implications

It is not unusual to encounter clients who present for treatment of certain psychological difficulties and mention in passing that they also smoke and cannot seem to quit. And cigarettes are just one drug of choice – most of us have clients with addictions to alcohol and other drugs (whether we know about it or not). Part of the trap of addiction is not just the onset of unpleasant withdrawal symptoms, but also the loss something that is like a dear, comforting friend. Just as acceptance and mindfulness can teach a client to relate in a different way to their unwanted thoughts and feelings, so also can it be used to relate to withdrawal symptoms and urges to return to substance use.

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Here is a more detailed summary of the study:

Though interventions are available that have demonstrated effectiveness in helping people quit smoking, cigarettes continue to be the leading cause of preventable deaths in the United States. Data on smoking habits suggest that a substantial subpopulation of smokers are unable to successfully quit and remain abstinent, and that these people commonly relapse within just a few days of entering treatment. Given that smoking becomes a habitual, addictive, and comfort-inducting activity over time, it is conceivable that this subpopulation is susceptible to relapse because of an inability to tolerate the distress of withdrawal and related symptoms. In fact, a simple breath-holding task has been shown to predict success rates upon entering smoking cessation treatment.

Given that Acceptance and Commitment Therapy builds willingness to have distressing internal experiences like urges, ACT treatment components were built in to a smoking cessation treatment involving pharmacotherapy and traditional exposure. Treatment consisted of six individual sessions, nine group sessions, and 8 weeks of transdermal nicotine patch usage. Participants were two cohorts of 8 smokers each, all reporting an inability to abstain from cigarettes for more than 3 successive days in the past 10 years.

Participants provided self-reports of smoking status at the conclusion of treatment as well as at 8-, 13-, and 26-week follow ups. Reports of abstinence were verified by expired carbon monoxide. A relapse was determined to be 7 consecutive days of smoking after quit day. Results showed that half the participants relapsed about 45 days after quit day, and that all participants relapsed by the 26-week follow up. Although relapse was shown to be inevitable, the amount of time abstaining from cigarettes was markedly longer on the average than any quit attempt in the past 10 years, and 82% of participants reported that the skills in the program were very or extremely useful in helping them quit. The authors point out that this pilot study represents the only known published attempt to work with early-relapse smokers. They report that data on a small, randomized controlled trial is forthcoming. For more on the use of ACT with substance abuse, check out: